Herpes Zoster Oticus in Emergency Medicine

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Herpes Zoster Oticus in Emergency

Medicine Overview of Herpes Zoster Oticus

Author: Christina Bloem, MD; Chief Editor: Steven C Dronen, MD, FAAEM more...

Updated: Mar 29, 2011

Overview of Herpes Zoster Oticus

Herpes zoster oticus (HZ oticus) is a viral infection of the inner, middle, and external ear. HZ oticus manifests assevere otalgia and associated cutaneous vesicular eruption, usually of the external canal and pinna. When associated

with facial paralysis, the infection is called Ramsay Hunt syndrome. (See the image below.)

Herpes zoster oticus. Image courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC OphthalmologyClinic.

Ramsay Hunt syndrome accounts for up to 12% of all facial paralyses and generally causes more severe symptoms

and has a worse prognosis than Bell palsy.[1, 2, 3]

Return-to-baseline neurologic function is predicted partially by

severity of paralysis. In several studies, only 10-22% of individuals with significant facial paralysis had complete

recovery. In one study, however, 66% of patients with incomplete paralysis had complete recovery.

An additional complication of herpes zoster viral infection is postherpetic neuralgia.

The incidence rates of HZ oticus in males and females are equal, and incidence increases significantly in patients

older than 60 years.

Pathophysiology of HZ Oticus

Reactivation of the varicella-zoster virus (VZV) along the distribution of the sensory nerves innervating the ear, whichusually includes the geniculate ganglion, is responsible for herpes zoster (HZ) oticus. Associated symptoms, such ashearing loss and vertigo, are thought to occur as a result of transmission of the virus via direct proximity of cranial

nerve (CN) VIII to CN VII at the cerebellopontine angle or via vasa vasorum that travel from CN VII to other nearby

cranial nerves.

Clinical Manifestations of HZ Oticus

Patient history

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MEDLINE

pes Zoster Oticus in Emergency Medicine http://emedicine.medscape.com/article/1952189-overview

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Typically, patients present with severe otalgia. Complaints include the following:

Painful, burning blisters in and around the ear, on the face, in the mouth, and/or on the tongue (see the imagebelow)

Herpes zoster oticus. Image courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLICOphthalmology Clinic.

Vertigo, nausea, vomitingHearing loss, hyperacusis, tinnitusEye pain, lacrimation

Onset of pain may precede the rash by several hours or days. Also, in patients with Ramsay Hunt syndrome, vesiclesmay appear before, during, or after facial palsy (zoster sine herpete). When asked, patients may recall a distant history,

perhaps in childhood, of chickenpox (varicella). A minority of patients (< 10%) give a history of previous herpes zosterviral infection.

Physical examination

Physical examination shows a vesicular exanthem, usually of the external auditory canal, concha, and pinna. The rashalso may appear on postauricular skin, lateral nasal wall, soft palate, and anterolateral tongue.

Vertigo and sensorineural hearing loss may be noted, and paralysis of the facial nerve, mimicking Bell palsy, may be

present. Complete loss of the ability to wrinkle the ipsilateral brow distinguishes a peripheral lesion of cranial nerve VIIfrom a central lesion of the same nerve, which spares the forehead.

Associated findings include the following:

Dysgeusia (alteration in taste)Inability to fully close the ipsilateral eye, which may lead to the occasional presentation of drying and irritation ofthe cornea.

Complications

Complications of HZ oticus may include the following[4, 5, 6] :

Postherpetic neuralgia

Residual paralysis

Rarely, herpes zoster encephalitis[5]

Etiology of HZ Oticus

Herpes zoster (HZ) oticus is caused by the reactivation of latent varicella-zoster virus (VZV) that has remained dormant

within sensory ganglia (commonly the geniculate ganglion) of the facial nerve. Individuals with decreased cell-mediatedimmunity resulting from carcinoma, radiation therapy, chemotherapy, or HIV infection are at greater risk for reactivationof latent VZV. Physical stress and emotional stress often are cited as precipitating factors.

Differential Diagnosis

The differential diagnosis of herpes zoster (HZ) oticus includes the following:

Bell Palsy

Headache, ClusterHeadache, Migraine

Headache, TensionHerpes ZosterOtitis ExternaOtitis Media


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Stroke, HemorrhagicStroke, Ischemic

Isolated facial nerve trauma also needs to be considered.

Laboratory Studies

Herpes zoster oticus (HZ oticus) is primarily a clinical diagnosis in the ED.

Prior to initiating treatment with acyclovir, consider a baseline set of the following laboratory studies:

Blood urea nitrogen (BUN)

CreatinineBlood cell countsElectrolytes

Imaging Studies

If diagnosis of Ramsay Hunt syndrome is not established by physical examination alone, consider a head CT scan to

investigate other etiologies of facial paralysis.

Treatment of HZ OticusUntil recently, therapy for herpes zoster (HZ) oticus has been generally supportive, including warm compresses,narcotic analgesics, and antibiotics for a secondary bacterial infection.

Antiviral agents

Antiviral agents clearly play a role in limiting the severity and duration of symptoms if given early in the course of theillness. Early administration (< 72 h) of acyclovir showed an increased rate of facial nerve function recovery andprevented further nerve degeneration. Furthermore, use of antivirals has been shown to decrease the incidence and

severity of postherpetic neuralgia.[7, 8, 9, 4]

Evidence is accumulating that varicella-zoster virus (VZV) may be responsible for many cases of Bell palsy that go

unrecognized because of a lack of cutaneous f indings (zoster sine herpete). Accordingly, the clinician should entertain

more liberal use of antivirals such as acyclovir, valacyclovir, and famciclovir.[2, 3]

Studies have shown no difference

between oral and IV acyclovir in immunocompetent patients with facial nerve paralysis.[10]

Corticosteroids

Systemic corticosteroids are used to relieve acute pain, decrease vertigo, and limit the occurrence of postherpetic

neuralgia. The prevailing wisdom states that treatment with acyclovir plus prednisone has more effective return to facialnerve function and prevention of nerve degeneration than treatment with prednisone alone; however, a recent review

uncovered very little data to support or negate this theory.[7]

Patients treated with acyclovir plus prednisone had betteroutcomes (time to healing of rash, time to cessation of acute neuritis, time to return to usual activity and sleep, and

time to cessation of analgesics) than those treated with either prednisone or acyclovir alone.[11]

No evidence indicates that use of corticosteroids prevents development of postherpetic neuralgia.[8, 9]

Furthermore,

evidence proving benefit attributed specifically to steroids is still limited, with one review showing no randomizedcontrolled trials supporting use of steroids as an adjuvant to antiviral medications in the treatment of Ramsay Hunt

syndrome.[12]

Treatment in HIV patients

For treatment of herpes zoster in patients with HIV, inpatient parenteral regimens should be reserved for those withsevere immunosuppression, trigeminal nerve involvement, ocular lesions, or multidermatomal involvement. Treatment

of VZV is the same for both HIV-seronegative and seropositive patients. For acyclovir-resistant VZV, IV foscarnet isan appropriate alternative therapy (famciclovir and valacyclovir are not effective against acyclovir-resistant VZV). For

outpatient regimens, famciclovir or valacyclovir for 7-10 days is recommended (both have the advantage of easierdosing regimens). Routine use of steroids is discouraged secondary to its immunosuppressive effects.

[13]

Treatment in other situations

Treatment of pregnant women with VZV is the same as that of nonpregnant women.


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When secondary impetigo is present, a suitable antistaphylococcal antibiotic should be prescribed.

Cyclic antidepressants, anticonvulsants, opioids, and topical analgesics are sometimes used in the treatment of

postherpetic neuralgia.[4] These agents are more appropriately started by a pain management specialist in an

outpatient setting.

Prevention of herpes zoster by vaccination is recommended for all persons older than 60 years, even if they have hadchickenpox or zoster in the past. This age group suffers significant morbidity from zoster and may, therefore, benefit

from the vaccine. Contraindications to vaccine administration include age younger than 60 years, current use of

antivirals, pregnancy, and certain immunosuppressive conditions.

[14]

Ensure that the patient has adequate and timely outpatient follow-up for management of HZ oticus.

Emergency department care

Adequate analgesia is important for individuals with significant pain from herpes zoster. Nausea and vomiting may

require ED treatment. Complications, such as corneal irritation or secondary bacterial infection of the vesicles, shouldbe managed with routine therapies. Involvement of more than one dermatome is atypical and should prompt thesearch for possible immunoincompetence.

Consider admission for any of the following situations:

Severe symptoms

Involvement of multiple (>2) dermatomesImmunocompromise

Consultations

Consider an ophthalmologic consultation if corneal involvement with vesicles is noted, and consider a neurologicconsultation if the etiology of the facial paralysis is unclear. Consultation with an ear, nose, and throat (ENT) specialistmay be appropriate.

Prognosis

Prolonged or permanent facial paralysis is possible. Most patients with partial paralysis fully recover; many with severe

symptoms are left with partial def icits.

Patient Education

Instruct patients how to tape eyes shut if lid paralysis is present.

Contributor Information and DisclosuresAuthorChristina Bloem, MD Assistant Clinical Professor of Emergency Medicine, George Washington University

Disclosure: Nothing to disclose.

Coauthor(s)Maria M Diaz, MD Staff Physician, Department of Emergency Medicine, Memorial Hospital

Maria M Diaz, MD is a member of the following medical societies: American College of Emergency Physicians,Emergency Medicine Residents Association, and Phi Beta Kappa


Christopher I Doty, MD, FACEP, FAAEM Assistant Professor of Emergency Medicine, Residency ProgramDirector, Department of Emergency Medicine, Kings County Hospital Center, State University of New YorkDownstate Medical Center

Christopher I Doty, MD, FACEP, FAAEM is a member of the following medical societies: American Academy ofEmergency Medicine, American College of Emergency Physicians, American Medical Association, Council of

Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine



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Jon Mark Hirshon, MD, MPH Associate Professor, Department of Emergency Medicine, University of MarylandSchool of Medicine

Jon Mark Hirshon, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, AmericanAcademy of Emergency Medicine, American College of Emergency Physicians, American Public Health

Association, and Society for Academic Emergency Medicine


Specialty Editor BoardRobin R Hemphill, MD, MPH Associate Professor, Director, Quality and Safety, Department of EmergencyMedicine, Emory University

Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency

Physicians and Society for Academic Emergency Medicine


Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center Collegeof Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Eric L Weiss, MD, DTM&H Director of Stanford Travel Medicine, Medical Director of Stanford Lifeflight, AssistantProfessor, Departments of Emergency Medicine and Infectious Diseases, Stanford University School of Medicine

Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency

Physicians, American College of Occupational and Environmental Medicine, American Medical Association,American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern SurgicalCongress, Southern Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical

Society


Chief EditorSteven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of EmergencyMedicine and Society for Academic Emergency Medicine


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